The Learning Playhouse

Registration Forms

 

Family Name _______________ Home phone # ____________

Home address ______________________________________

Child’s name _____________age____ birthday_____________

Health card # _______________ Allergies _______________

Child’s name _____________age____ birthday_____________

Health card # _______________ Allergies _______________

Child’s name _____________age____ birthday_____________

Health card # _______________ Allergies _______________

Mother’s name_________ Employer______________________

Work #__________________ cell # ___________________

Father’s name_________ Employer______________________

Work # _________________ cell # ____________________

Emergency contact person _____________________________

Daytime # ________________ cell # ___________________

2^nd emergency contact person __________________________

Daytime # ________________ cell # ___________________

Name of persons allowed to pick up ______________________

_________________________________________________

Family Physician _______________ phone # ______________

Address _______________________

Date ____________ Parents Signature __________________

                                   Parents Signature __________________

 

 

 

 

 

 

 

 

 

 

Consent for Emergency Treatment

 

We give permission for our child(ren) ____________________

to receive emergency treatment (first aid, C.P.R.) by The Learning Playhouse

We also give our permission for the above child(ren) to be transported by ambulance, car, or any way Mrs. Laurie feels is necessary to an emergency center for treatment.  We agree to pay any costs that may occur.

In the event that we cannot be contacted, we further consent to the medical, surgical and hospital care treatment and procedures to be performed for the above child(ren) by a licensed physician or hospital when deemed immediately necessary or advisable by the physician to safeguard our child(ren)’s health.

We give consent for The Learning Playhouse to administer over the counter type medication (Tylenol, Dimetapp, Diaper cream, Sun Block etc…) to the above child(ren).

We give consent for The Learning Playhouse to administer prescription medication to the above child(ren) this being in the original container with the child’s name, date prescribed and dosage on the label.

 

Father’s name and signature ___________________________

Mother’s name and signature ___________________________

Date ____________

 

Please include a copy of each child’s immunization record for their file.

 

 

 

 

 

 

 

 

 

 

 

 

General Consent Form

 

We give consent for our child(ren) ____________________

to go on scheduled/unscheduled walks and trips by car (each child will be in the appropriate car restraint.

We give permission to take the above child(ren):

Permission requested for	Yes	No	Initials
Transport in my vehicle with proper child restraint within the Durham Region
To go for walks around our neighbourhood
To go swimming in our kiddie pool
To take photos
To post photos & artwork on website
To give an occasional sweet treat
To assist with toilet training procedures
To give my phone # to other parents
To attend playdates
To bathe a soiled child if necessary

 

Parents Signature ___________________________________

Date _______________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Helpful Information

 

Does your child(ren) have any fears or dislikes: _____________
_________________________________________________
_________________________________________________

 

What are your child(ren)’s favorite activities _______________
_________________________________________________
_________________________________________________

 

Special instructions concerning care _____________________
_________________________________________________
_________________________________________________
_________________________________________________

 

What discipline techniques do you use at home ______________
__________________________________________________________________________________________________

 

Thank you for trusting me with your precious little ones and I look forward to working with you.  Please feel free to discuss anything with me and let me know of any changes to these forms or in your child’s life as it could help me care for them better.